Topic 12 - chronic venous disease

Question 1

What are the two main types of valves?

Answer 1

• ostial and parietal

Question 2

What is an ostial valve?

Answer 2

o form at the opening of venous tributaries
o These valves occur at the confluence of tributaries as they drain into the deep veins or main superficial veins but prevent back-flow into the tributary.

Question 3

What are parietal valves?

Answer 3

o form in the vein segments between the tributaries and are typically bicuspid or tricuspid in the lower limb.
o These valves prevent the extended back-flow or reflux of blood following augmentation by calf muscle pumps.
o The number of parietal valves present in the deep or superficial veins of the leg varies

Question 4

What is chronic venous disease (CVD)?

Answer 4

covers a range of changes in the veins, skin and lymphatic drainage

Question 5

What are some symptoms of CVD?

Answer 5

symptoms ranging from mild itching and swelling to severe ulceration of the skin.

Question 6

What is a contributing factor to CVD?

Answer 6

• Venous Incompetence

Question 7

What are changes in the vein wall during CVD?

Answer 7

• loss of endothelium
• inflammation
• neovascularisation (particularly associated with ulcers)
• increase in wall thickness
• fibrosis of the wall
• loss of smooth muscle function
• destruction of the venous valves

Question 8

What are some hemodynamic and physical changes of CVD?

Answer 8

• loss of calf muscle pump efficiency
• stasis of the limb venous blood pool
• Loss of ankle motion

Question 9

How is venous flowmaintained?

Answer 9

Supine -
• Without the effect of gravity on the veins, venous flow is generated by the pressure difference between the heart and the periphery.
• This is generated by the capillary flow and can be measured at about 15 mmHg.

Standing -
• On standing, gravity begins to increase the pressure in the veins in a direction opposite to that of the normal venous flow direction.
• Venous valves simply prevent blood volume (mass) from returning toward the foot.
• The calf muscle pumps assist us to actively return blood to the heart whilst in a standing or partially standing position

Question 10

Where are the lower leg muscle pumps located?

Answer 10

• Foot (augments on standing or walking)
• Calf
• Thigh

Question 11

How does venous pressure change while walking?

Answer 11

• During normal locomotion, blood is pumped during the active contraction of the leg muscles and the venous pressure reduces.
• At times when the majority of the muscles are relaxing, the venous pressure rises due to the lack of augmented flow and refilling of the empty veins form capillary flow.
• As the heel returns to the ground, it takes about 25seconds for the venous pressure to return to resting values

Question 12

How is venous pressure affected while walking in a patient with CVI?

Answer 12

• the augmentation of the blood by the muscle pump may be impaired, thus causing less fall in pressure than expected or no pressure fall at all.
• During the stages when muscles are relaxed, an incompetent venous system will allow a greater volume of blood to return (or fall) back into the veins and return the venous pressure to that of a standing person more quickly.
• Both the impairment of the calf muscle pump and quicker filling of the veins causes the venous pressure to be higher (reduced less) than in a normal person.

Question 13

what is Ambulatory Venous Hypertension ?

Answer 13

• ‘raised’ venous pressure is termed Ambulatory Venous Hypertension and is often referred to as ‘venous hypertension’ in many texts.
• It does not represent a pressure which is higher than that seen in a standing and stationary person, but it is higher than expected from a person with normal functioning veins.

Question 14

What causes ulceration?

Answer 14

Venous hypertension causes a chronic elevated pressure in the post-capillary venules and this leads to damage of the capillaries and possible ulceration.

Question 15

What are the risk factors for varicose veins?

Answer 15

• Young and female
• Older and male
• Family history of varicose veins
• Pregnancy
• Giving birth to 3 or more children
• Having experienced a deep vein thrombosis in the past

Question 16

What are he main symptoms of CVD?

Answer 16

• skin pigmentation (discolouration)
• Itching
• weeping dermatitis
• ulceration
• lipodermatosclerosis
• swelling
• heaviness of the leg
• aching

Question 17

What are the non surgical options for treating varicose veins?

Answer 17

• The most important and effective - compression bandaging and stockings.
• Venoactive drugs

Question 18

What are the surgical options for treating varicose veins?

Answer 18

• Direct surgical disruption of the incompetent veins or ablation with chemical, thermal, laser or mechanical devices

Question 19

What is the purpose of ultrasound examination of CVD?

Answer 19

• to identify which veins are refluxing and where those veins communicate to the deep veins and to other superficial venous systems.
essentially a mapping process

Question 20

What are the different networks of veins?

Answer 20

• posterior thigh
• anterior thigh
• medial thigh
• posterior and lateral calf

Question 21

What are accessory veins?

Answer 21

The great, small and anterior accessory saphenous veins run in defined fascial sheaths.
Once outside these fascial planes, they are termed accessory veins of whichever saphenous vein you are looking at.

Question 22

What is venous reflux?

Answer 22

• Reflux is the abnormal back-flow or retrograde flow of blood in a given vein

Question 23

What measurement signifies reflux?

Answer 23

• The terms reflux or significant reflux are generally accepted as retrograde flow lasting longer than 0.5s in the superficial veins and longer than 1.0s in the deep veins.

Question 24

What are perforating veins?

Answer 24

• By convention the perforating veins direct blood from the superficial to the deep veins in order to maximise the efficiency of the calf muscle pump.
• However, some perforating veins are valveless and others are known to direct blood toward the superficial veins

Question 25

What should be examined in a CVI exam?

Answer 25

examination of the deep and superficial veins for the presence of reflux and thrombotic obstruction
• Calf perforating veins
• Calf deep veins
• Short saphenous vein and its tributaries
• Saphenopopliteal junction
• Popliteal vein and medial gastrocnemius vein
• Sapheno femoral junction with pelvic communicating tributaries
• Great saphenous vein and its tributaries (including incompetent accessory tributaries)
• Femoral vein
• Any incompetent vein which communicates directly to the pelvis

Question 26

What is post thrombotic syndrome?

Answer 26

• Incomplete resolution of the clot or inadequate revascularisation will promote the formation of collateral veins to bypass the obstructed venous segment.
• collateral paths may be formed by new vein formation or by greater use of the existing superficial and deep femoral vein pathways.
• In cases where the alternate collateral pathways cannot drain the limb effectively, venous pressure will increase below the level of the obstruction.
• increase in venous pressure over time can result in chronic limb swelling and skin changes including ulceration.
• In severe cases of obstruction the raised venous pressure will impair capillary flow and may even reduce arteriolar inflow, causing ischemia and venous gangrene.
In addition to residual clot, the process of clot resolution may leave the venous wall and valves damaged, thus causing venous reflux.

Question 27

What is Phlegmasia Alba Dolens?

Answer 27

describes the patient with swollen and white leg because of early compromise of arterial flow secondary to extensive DVT. This condition is also known as “milk leg,”

Question 28

How does phlegmasia alba dolens present?

Answer 28

• presents as a triad of edema, pain, and white blanching skin without cyanosis.
• As the venous thrombosis progresses, it develops into phlegmasia cerulea dolens, which is characterized by edema, worsening pain, and cyanosis from ischemia.

Question 29

What are the common causes of phlegmasia alba dolens?

Answer 29

• In cases of pregnancy most often seen during the third trimester, resulting from a compression of the left common iliac vein against the pelvic rim by the enlarged uterus.
• Today, this disease is most commonly (40% of the time) related to some form of underlying malignancy

Question 30

At what stage does phlegmasia alba dolens become phlegmasia cerulea dolens?

Answer 30

• begins with a deep vein thrombosis that progresses to total occlusion of the deep venous system.
• It is at this stage that it is called phlegmasia alba dolens.
The next step in the disease progression is occlusion of the superficial venous system, thereby preventing all venous outflow from the extremity. At this stage it is called phlegmasia cerulea dolens.

Question 31

What are the risk factors for phlegmasia cerulea dolens?

Answer 31

• malignancy
• prothrombotic state
• inferior vena cava filter
• trauma
• venous stasis

Question 32

What is the clinical presentation of phlegmasia cerulea dolens?

Answer 32

It is characterised by a clinical triad of acute limb swelling, cyanosis and severe acute pain.

Question 33

What are the complications of phlegmasia cerulea dolens?

Answer 33

• significant risk of massive pulmonary embolism, even with anticoagulation
• 40-60% develop gangrene of the periphery
o due to increased compartmental pressures from severe venous congestion and oedema
• 20-50% mortality
• amputation rate as high as 25% in survivors

Question 34

How are pelvic veins and varicose veins of the leg sometimes related?

Answer 34

• The presence of vulval or peri-vulval varices is frequently associated with pelvic congestion syndrome and can be associated with incompetence of the left and right ovarian veins.
• In these cases the ovarian veins reflux through the veins of the broad ligament to the vulval tributaries and communicate with recurrent or primary varicose veins in the leg.

Question 35

How is the patient set up to assess ovarian vein incompetence?

Answer 35

• This is a procedure that must be done with the patient at > 60 degrees to the supine position

Question 36

Which veins are assessed in an ovarian vein incompetence study?

Answer 36

• Para-ovarian/uterine veins
• Right and left ovarian veins
• Left renal vein
• Right and left internal iliac veins

Question 37

What ultrasound measurements are made in an ovarian vein incompetence study?

Answer 37

Measurements: B-mode
•	Para-uterine veins: supine and > 60 degrees
•	Left ovarian vein: superior (AP diam)
•	Right ovarian vein: superior (AP diam)
Measurements: Spectral
•	Left ovarian vein
•	Right ovarian vein
•	Right internal iliac spectral trace
•	Left internal iliac spectral trace

Question 38

How do patients with ovarian vein incompetence often present?

Answer 38

• Often, these patients present to the vein clinic with recurrent varicose veins, because the standard procedures have failed and the pelvic origin was not recognised.

Question 39

How is diagnosis established in relating recurrent varicose vein to pelvic vein incompetence?

Answer 39

• To establish diagnosis, the communication from the atypical varicose veins in the legs to the ovarian veins must be shown and incompetence of one or both ovarian veins must be demonstrated

Question 40

What are the two most common pathways between the ovarian vein and leg veins?

Answer 40

1. Postero-medially from the perineum into the posterior branch of the LSV
2. Via the Ext pudendal V into the SFJ.

Question 41

When is reflux not significant?

Answer 41

When is occurs at a vein junction

Question 42

The criteria and markers of perforator incompetence include:

Answer 42

Spectral time: >0.5 sec, >1.0sec or just simply reversed flow
Size: > 3mm or > 4mm
Relationship to VV’s

Question 43

What size ovarian vein indicates reflux?

Answer 43

A measurement of 1.0cm is considered conclusive of LOV reflux